منابع مشابه
Case report of a medication error
INTRODUCTION The World Health Organisation recognizes confusing drug names as one of the most common causes of medication errors. Other factors include spelling, phonetic, or packaging similarities. CASE PRESENTATION We presented a case report of an inadvertent administration of a non-ocular pharmaceutical product (Novasone lotion) into the eye of an octogenarian individual, and briefly revie...
متن کاملMedication Error, What Is the Reason?
Background: Medication errors due to different reasons may alter the outcome of all patients, especially patients with drug poisoning. We introduce one of the most common type of medication error in the present article. Case: A 48 year old woman with suspected organophosphate poisoning was died due to lethal medication error. Unfortunately these types of errors are not rare and had some preven...
متن کاملCase Report: Comprehensive Analysis of a Medication Dosing Error Related to CPOE
This case study of a serious medication error demonstrates the necessity of a comprehensive methodology for the analysis of failures in interaction between humans and information systems. The authors used a novel approach to analyze a dosing error related to computer-based ordering of potassium chloride (KCl). The method included a chronological reconstruction of events and their interdependenc...
متن کاملWarfarin and Rivaroxaban Duplication: A Case Report and Medication Error Analysis
A 62-year-old African American man received unintentional duplicate anticoagulation therapy with warfarin 5 mg and rivaroxaban 20 mg daily for the treatment of recurrent pulmonary embolism. The patient presented to the anticoagulation clinic 6 days after hospital discharge with an International Normalized Ratio (INR) of 2.3 and he was instructed to continue warfarin 5 mg daily. Seven days later...
متن کاملذخیره در منابع من
با ذخیره ی این منبع در منابع من، دسترسی به آن را برای استفاده های بعدی آسان تر کنید
ژورنال
عنوان ژورنال: Hospital Pharmacy
سال: 2017
ISSN: 0018-5787
DOI: 10.1310/hpj5204-249